A matter of restraint

April 17, 2015

Patients should only be restrained as a last resort and restraints must never be used simply for the convenience of staff or to help them manage workloads, the AMA has advised.

A Senate inquiry into dementia care last year raised concerns of “a troubling trend in which there is an increased use of restraints as a management tool for [dementia symptoms],” and Alzheimer’s Australia claimed 140,000 nursing home residents were being restrained with drugs.

The Chair of the Senate inquiry, Australian Greens Senator Rachel Siewert, said the committee heard evidence that medication, locked rooms and physical restraints were all measures used to restrain dementia patients, including where they were used “for convenience and the protection of facilities, rather than the clinical needs of the patient”.

In Position Statement released last month, the AMA said that although the use of restraints for such purposes was unacceptable, there were circumstances where they were appropriate.

But it cautioned patients should only be restrained only after careful consideration and consultation, and having exhausted all reasonable options.

The AMA said the decision of whether or not to use a restraint involved finding a balance between the patient’s right to self-determination and protection from harm, and the possibility of harm to others.

While ultimately it was a call for the treating doctor, the AMA said the decision should be arrived at through a process of request, assessment, team involvement and consent.

“The prime purpose of restraint should be the safety, wellbeing and dignity of the patient, and should take into account any previously expressed or known values or wishes,” the Position Statement said. “In the short-term, the welfare and protection of others, and the statutory occupational health and safety obligations on employers, must also be considered.”

Where restraints are used, they should be of the least restrictive nature possible, and their use should be viewed as a temporary solution.

While mention of restraints often conjures images of patients strapped to beds, the Senate inquiry found that increasingly it involved the use of psychotropic drugs or locked rooms.

But the AMA advised the use of such drugs to reduce distressing symptoms, or as a specific treatment for delirium, anxiety, depression, psychosis or symptoms of dementia, “does not constitute restraint, and they should not be withheld”.

AMA Vice President Dr Stephen Parnis said there was a clear distinction between using such drugs to treat a patient with a diagnosed illness and using them for the sole purpose of restraint.

“Psychotropic medications are a clinically appropriate treatment for older people with medical conditions such as anxiety, depression, psychosis and dementia,” Dr Parnis said. “They can be very effective in assisting a person to become settled in their environment.”

But he said restraints – chemical or otherwise – should only be used as a last resort, and for the shortest possible period, and argued that their use could be “considerably minimised” by ensuring there were adequate resources, that staff were appropriately trained in how to engage with residents, and facilities were designed to minimise stress.

Most of the revisions to the Position Statement were informed by the 2012 Department of Health and Ageing Decision Making Tool: Supporting a restraint free environment in residential aged care, which is available at: ///C:/Users/jflannery/Documents/Downloads/Decision+Making+Tool+Supporting+a+Restraint+Free+Environment+in+Residential+Aged+Care.pdf